The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 DEDUCTIBLES, COINSURANCE AND MAXIMUMS Note: If you are enrolled in Kaiser Colorado, UnitedHealthcare or Medica Plan options, this information does not apply to you. Please see the separate Kaiser, UnitedHealthcare or Medica Plan options materials. Deductibles A deductible is the per plan year amount you must pay toward eligible expenses before you and the health care option begin to share covered expenses. The deductible is applied to the out-ofpocket maximum. The medical and pharmacy deductibles under the health care options work differently as explained below. The deductibles stated are for in-network/participating providers only. Information for out-of-network/non-participating deductibles can be found in the “Health Care Option Summary” section in this SPD. Early Retiree Medical Option The Early Retiree Medical option has a combined medical/pharmacy deductible and the deductible is non-embedded, which means: • If you elect the Individual coverage level, you only need to meet the per person deductible of $2,000. • If you elect the Family coverage level, you will need to meet the Family deductible of $3,000. The Family deductible can be met by one covered member or any combination of covered members. The per person deductible does not apply. Example 1. Sally is covered under the Early Retiree Medical option at the Individual level. She must have eligible expenses of $2,000 before she and the Program begin to share covered expenses. Example 2. Joe is covered under the Early Retiree Medical option at the Family level. He and his spouse must have eligible expenses of $3,000 before he and the Program begin to share covered expenses. Example 3. Tim is covered under the Early Retiree Medical option at the Family level, with his spouse and two children enrolled. He and his family must have eligible expenses of $3,000 before he and the Program begin to share covered expenses. For the Early Retiree Medical option the following charges do not apply to your combined medical/pharmacy deductible: • Your monthly health care premiums. • Any costs not covered by your option. • Any amounts that exceed the Program's allowed amounts when non-participating providers are used for medical services. In certain locations, this also applies when out-of-network providers are used. Refer to the “Which Network Providers to Use” section in this SPD for more information. • Any penalty for failing to provide required preadmission notification. 24
Retiree Health Care SPD Effective January 1, 2012 • Any amounts that exceed the Program's allowed amounts when a non-participating Retail Pharmacy is used for pharmacy services. This also applies if you use a participating Retail Pharmacy, but do not show your Medco ID card or for compound prescriptions not submitted directly to Medco by the pharmacy. • Any cost difference between a brand-name drug and a generic equivalent when a brand-name drug is prescribed and a generic drug is available. • Specialty drugs not filled by Accredo (a division of the Medco Pharmacy for specialty drugs) when required. • Any maintenance medications not filled by the Medco Pharmacy (Medco’s mail order service) after the first two fills when required. Comprehensive Option The Comprehensive option has separate medical and pharmacy deductibles, they are not combined and this deductible is embedded, which means: • If you elect the Individual coverage level, you only need to meet the per person deductible of $600. • If you elect the Family coverage level (but only have one or two covered dependents), you will each be responsible for the per person deductible of $600. • If you elect the Family coverage level (with at least 3 covered dependents), the family deductible of $1800 can be met by any combination of three or more covered members. Example 1. Ron is covered under the Comprehensive option at the Individual level. He must have eligible expenses of $600 before he and the Program begin to share covered expenses. Example 2. Alice is covered under the Comprehensive option at the Family level, with only her son enrolled. Both she and her son must each have eligible expenses of $600, before she and the Program begin to share covered expenses. Example 3. Barb is covered under the Comprehensive option at the Family level, with her spouse and three children enrolled. If Barb and her spouse and one of her children has $1,800 in eligible expenses, the Program will share covered expenses for any of the covered family members. For the Comprehensive option the following charges do not apply to your medical deductible: • Your monthly premium contributions for Program coverage. • Any costs not covered by your option. • Any amounts that exceed the Program's allowed amounts when non-participating providers are used for medical services. In certain locations, this also applies when outof-network providers are used. Refer to the “Which Network Providers to Use” section in this SPD for more information. • Any penalty for failing to provide required preadmission notification. • Amounts paid toward the pharmacy deductible. • Coinsurance and copayments for retail, Medco Pharmacy (Medco’s mail order service) and Accredo (a division of the Medco Pharmacy for specialty drugs). • Copayments for emergency room visits. • Charges that are not eligible to be applied to the pharmacy deductible are also not eligible to be applied to the medical deductible. See the “Pharmacy Deductibles, Coinsurance and Maximums” section in this SPD for the list. 25
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The eligibility and enrollment rules for the U

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